Provider Demographics
NPI:1043701931
Name:SHORT, STACY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SPYGLASS CIR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6334
Mailing Address - Country:US
Mailing Address - Phone:208-552-0638
Mailing Address - Fax:
Practice Address - Street 1:380 SPYGLASS CIR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-6334
Practice Address - Country:US
Practice Address - Phone:208-552-0638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist